Pictures from weekend trip to Hillcrest Berry Farm. On our way back took some pictures of the wine valley and some passing pedestrians, such little monkeys! (Which picture!!?:D)  There was a big troop of them. 

DAY TO DAY

Before coming here we were all uncertain what our day-to-day life would be like. What we did know was that we had 500 charts of patient’s who had a chest tube (ICD) placed from GF Jooste hospital to review, those charts had to be cross checked with the tuberculosis (TB) database, all the data had to be inputted into the computer, and a statistical analysis of the data would be done.

Let me explain now how that has played out. The culture here is either very trusting or very lax, which ever you prefer! And all the records are paper copies, nothing is electronic. When a patient comes into the Casualty (ER) they go to the admission window and get a folder handed to them with preprinted labels. They bring that folder with them into the casualty room, which is an open pit. There is supposed to be a clerk by the door ‘checking’ patients in from admission but most of the time no one is there. So the patient comes up to anyone they see who looks like they work there and hand them their chart. We have had charts handed to us many times while we are doing chart reviews (naturally anyone reading a chart should in fact be a doctor). The patient finally finds a nurse who will do intake vitals on them and get them situated in the casualty. The nurse then registers the patient into the casualty registry book, a hand written log with patient name, patient folder number, reason for visit, and doctor assigned to the patient. Patients are then seen by the casualty doctor for treatment and referrals to an in-patient ward or other hospital.

Patients who need an ICD put in are sent to the surgical ward (10 feet away) and are registered into the surgical book. A chest tube is placed when there is risk or evidence of a collapsed lung from trauma. For our project we are only looking at penetrating trauma requiring an ICD, like that of a stabbing or gun shot wound.

Step one of our project was then going through the surgical registry books looking for all patients with an ICD placement. Our study protocol called for any patients with an ICD from 2004-present. From two registry books (the size of a very large yearbook) we had over 500 ICD’s. We made one complete list of all 500 of the patient folder numbers associated with the ICD patients. These happened to be all from 2006 and 2007.

Step two was going to the records department and pulling our charts. The first week or so we did it ourselves. I explained myself once the first day to one of the staff and they were okay with me coming in there. After we did two overnighters however we were told we must call the Director of Records and explain who we were and what we were doing. After that phone call we set up a wonderful system of the staff pulling 50 charts at night and 50 charts in the morning and just keeping them stacked up for us. (There is a sign saying “These charts are for a research project for doctors”.  That reminds me, in order to get access I am registered as a ‘visiting medical student’. I have a student ID card and everything. Who knew you could get a medical degree as a student at DU!) For the last 4 weeks that is what we have been doing. We had pulled 448 charts of 500 as of this Monday.

The first week or so we did our chart review at a tiny coffee table sized table in the records office. There were no chairs so we would either stand or end up sitting on the tile floor (not the cleanest!). When that got too much we moved out the casualty room and squeezed onto the side of the table in the center. There wasn’t’ ever a really conducive place to sprawl out with our folders. Through a series of events we eventually found the research resource room that has a conference room sized table. We have happily been using this room ever since.

Step three was cross-referencing our data with the electronic TB registry called ETR.net, which we have been trying to get access to since day one. That has been quite the fiasco and we have been given a bit of run around with it. In the mean time we have also been hearing varied stories of the reliability of TB data at Jooste. Apparently TB tracking has only really been happening within the last year - year and a half. Even then it also has low compliance because it relies on the doctors calling the research center and referring a patient for TB testing/counseling/treatment. Of all the hospitals in the Western Cape, Jooste has the poorest record for TB compliance.

On Tuesday we finally spoke with a women at the Department of Health who could get us access to ETR.net, kind of. We can’t access it ourselves as we thought, but we can give her a list of all the patients we need and she can pull a master report for us. That was time saving news to here. Also on Tuesday, through another source, we ultimately came to realize that a very, very small percentage of our ICD patients from 2006-2007 might in fact be in ETR.net due to the lack of records. Without the cross referencing capability there would be no way of confirming TB and/or HIV in our patients. Thus we could not test our study hypothesis that TB and/or HIV patients experience greater morbidity and complications associated with ICD placement. Not good news to hear after 4 weeks of work! But thankfully our team is pretty resilient and dedicated to this project.

We decided to recreate our list of ICD patients using only patients from 2008-2009, when ETR.net was ‘regularly’ used. We created a new master list of 500 patients, dropped it off at records Wednesday and started “Project #2”, as we are now calling it. We have a week left in our project/internship. It’s crazy to think about restarting the project that had taken us 4 weeks before, with only 1 week left. However there are some great learning lessons in this. We definitely feel that we worked out a lot of kinks in Project #1 including consistent data collection on our part, and learning more about the charts and thus adding a few items to our data collection forms for Project #2.  As our fearless leader back in the states said, “We have perfected this to a science”! Two eight-hour days with only tea breaks have already give us 200 charts.

Step four is data entry, the fun stuff. We just finished inputting the data from Project #1 last night. We are focusing on getting the charts reviewed now given our time crunch and then will do data entry for Project #2 next week. Then will turn around and give a report of patients to our Department of Health contact of all our patients and see which ones exist in ETR.net. All by next FridayJ

Step five will be the data analysis and I’ll do that back in the states. We are all every interested to see what results we get. Even looking at our current data regardless of TB status- see the ratio of men to women, mean age, whether there are more complications from ICD’s placed at the day hospitals than at Jooste, etc. And because we have Project #1 and Project #2 with two distinct time frames we can also look at differences over time. So all is not wasted here and we are all about slaphappy with exhaustion over it. 

REFERAL SYSTEM

In working, discussing or understanding South African health care it is important to understand the referral system. Like most other referral systems, i.e. HMO’s, a patient must go to his primary care doctor and get a referral to a more specialized doctor for any complication or procedure his/her primary care doctor cannot perform.

As we’ve explained to some of you, a patient who needs an ICD (chest tube) is required to go to a local day hospital/community care center (aka his primary care doctor). The day hospital can place the ICD but they do no further ICD treatment. The patient is then referred up to the local secondary hospital, like Jooste. On referrals a patient is transported between referrals via ambulance and ‘porters’. (That is good news; we had thought it was the patient’s own responsibility to get from referral to referral.)

Patients transferred to Jooste are admitted into the casualty (ER) from the day hospital. The casualty doctor’s evaluate them and once the patient is stable the transport them to the ICD ward at Magnolia hospital. The ICD has physical therapist there to assist in breathing exercises and rehabilitation. After the patient is ready for discharge, they are transported back to Jooste for discharge where the ICD is removed, the site is sutured and the patient leaves. From our research, it appears most patients only stay about 3 days.

The general consensus of the referral system is that it’s a bit frustrating and better in theory. The theory is that when there are such few resources, they must be maximized as greatly as possible. So day hospitals are pretty common and have only the basic care resources. Moving up the referral system chain, the next level health care facility will have a bit more resources to treat a few more complications. And ultimately the highest-level health care facility in the referral system has the most advanced technology for the area. This way the Department of Health does not have to have machines at every hospital, only at the perspective secondary, tertiary, etc.  (For instance there are only 3 modern ultrasound machines in the Western Cape region and they are all at the higher referral hospitals). The referral system follows South Africa’s general sense of hope, as it was said to me. It’s a system based on hope that there are no complicated patients. That a patient with a cold can simply go to the day hospital for treatment. And that the cold is not in fact a complication from ARV’s and a sign of system failure that would require more advanced treatment than that available at a day hospital.

We can all understand the frustration with referral systems with our own understanding of the HMO system. Now just think about this in an emergency situation, when you can’t wait 2 weeks for a new appointment. In the states a patient would arrive at the ER and be rushed to surgery if needed. In this referral system a patient must go to the day hospital first, then get referrals to more advanced treatment. Of course if a patient arrives at Jooste without a referral letter from a day hospital he/she will still be treated. In that regard I don’t quite understand the consequences a patient would face if he/she just arrived at the highest-level care requesting treatment. 

The Full Moon of Cape Town and the 4 travelers

Camps Bay at Sunset

Sunset and Moon Rise from the Top of Lion's head

The moon rising over Table Mountain. 

Tales from the Casualty

Today's fun fact is the South African term for Emergency is "Casualty".  Therefore EM docs are Casualty doctors here.  

We know that we haven't done an update in 2 weeks, so I thought I could do a little piece I like to call "Tales from the Casualty".  

Rusty and I have worked every weekend night shift in the past 2 weeks, which has made for some intense stories.  I don't need to go into all of the victims of violence that we see here, but I just wanted to share a few highlights (for lack of a better word).

Two weekends ago, I was standing in the Resuscitation Room (aka Trauma Bay) and I glanced over my shoulder and there was a young man who was just wheeled into the ED and he looked at me through the glass doors of the resuscitation room, then his head dropped and he died.  So I jumped up, ran over to him, and immediately noticed that his shirt was completely covered in blood.  By the time I got to him, the nurses and doctors did as well.  So we grabbed him, threw him onto the gurney and attempted to resuscitate him. I cut off his clothes and saw the wound--he was stabbed fatally in the axilla (armpit) and his axillary artery was severed.  Rusty and I got his IV started and simply did chest compressions.  20 minutes later, we got his heart rate and pulse back, then the surgeons took him and he died during surgery.  

The next day, and a few resuscitations later, an older man was brought in on stretcher in respiratory arrest, so I intubated him while Rusty did compressions and got his arterial blood gas.  Again, we got his pulses and heart rate back, and he died later in the ICU.  

The night was finished off with a young girl, 6 months pregnant, whom was hit in the face with a brick and fell onto her abdomen.  The girl and the baby ended up fairing well, and I got to do my 2nd fetal ultrasound (and stitch her face).

Then, last weekend, we were told that all the action happens on the first weekend of the month, because the government checks get sent out and people party, get drunk, get high, etc and as a result, Casualty is crazy.  This proved to be true.

Last Saturday, there were two rival gangs walking around the neighborhood and assaulting anybody in the street.  The police ended up arming themselves with machine guns and drove around the city streets arresting anybody outside, for any reason.  Sure enough, the victims of the gangs, would come in, one after another.  In addition to the typical busy Saturday, we had about 15 extra people who were bleeding from stab wounds and head injuries from gang violence.  So Rusty and started sewing these people back together.  We got through about 6 patients and we realized that we had run out of suture kits.  After a hospital wide search, we found out that the entire hospital had run out of suture kits and that the bleeding patients just had to stand in the corner and bleed on the ground.  After about 3-4 hours of watching these people moan and bleed, we finally got some Debridement kits (not suture) and separated out the tools in the Debridement kits that we could use for suturing.  Eventually, 6 hours later, we finally got all of their lacerations sewn up.  T.I.A.  

One couple that I treated had been out drinking with a "friend".  At some point, during the night, the "friend" hit the female over the head with a beer bottle a few times, until the bottle broke, of course, then took the jagged end of the bottle and stabbed the male in the face.  The friend then put the female and the male in his car and was driving them to the countryside where he was going to murder them.  The male finally regained consciousness and jumped from the moving car, the female followed him, breaking her leg.  

Another 3 people that we treated were all family.  A gang member just broke into their shack and attacked the whole family in their sleep.  He stabbed the teenage daughter in the face, he stabbed the 60 year old mother in the chest and he stabbed the brother in the back. These 3 people all ended up surviving, but in my opinion, the teenage girl got the worst of it, because her face will be scarred for life.  Rusty did a great job on suturing her face, with our make shift kits.  I sewed the mother, who had an arterial bleed that sprayed in my face a few times (I wore goggles).  

Lastly, Rusty and I work the Casualty Department, so that we can teach the doctors and residents how to use the ultrasound machine in a trauma situation.  Sure enough, we had a young man who was stabbed in the chest, just anterior to the heart.  The doctors and surgeons were voting on whether to take him directly to surgery, or watch and wait, because they couldn't tell if his heart had been stabbed, or just his lungs.  Rusty and I grabbed the ultrasound machine and scanned him.  We immediately picked up on his pericardial effusion (meaning that his heart had in fact, been stabbed).  The surgeons immediately took him to the OR.  Later that night the surgeon came out of surgery and thanked us, because the patient had a right ventricle stab that they saw during surgery.  As we like to joke here, "Another life saved".  Haha. 

Rusty and I have also had the opportunity to do several lumbar punctures (spinal tap) on meningitis patients.  Additionally, the doctors here have promised us the chance to do all the chest tubes that come in while we are working (how many CU students are doing that??)!! 

As for fun stuff.  Ofer got here a week ago and we have been trying to entertain him by showing him around a bit, between shifts.  The four of us (Megan, Rusty, Ofer and I) got a chance to climb Lion's Head at sunset and watch the full moon rise over Table Mountain.  We then climbed down in the dark and went to our favorite 2 for 1 burger joint!   It was amazing!  

Right now we are in our final push to finish the research portion of our time here.  We have had some major set backs, but we think it is possible to finish the research project. Wish us luck!